Provider Demographics
NPI:1245610344
Name:BENNALLACK, GUY RICHARD JR (DO)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:RICHARD
Last Name:BENNALLACK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E CHURCH ST BLDG 8
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5906
Mailing Address - Country:US
Mailing Address - Phone:805-739-3374
Mailing Address - Fax:
Practice Address - Street 1:1400 E CHURCH ST BLDG 8
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454
Practice Address - Country:US
Practice Address - Phone:805-739-3561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS3795207P00000X, 207Q00000X
CA20A15415207P00000X
CAXXXXXXXXXX207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine